| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
175 |
173 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
100 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
116 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
141 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
72 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
28 |
$905.85 |
| D1206 |
Topical application of fluoride varnish |
29 |
28 |
$453.06 |